Stable Angina Pectoris

Usual Causes
Occurs when an oxygen demand-supply mismatch occurs in
the myocardium.
The MOST common cause of typical angina pectoris is
atherosclerotic disesase of the epicardial coronary arteries.
Other LESS common, cause include epicardial coronary
spasm, Kawasaki disease, microvascular coronary disease,
aortic stenosis, hypertrophic cardiomyopathy, coronary
fistulas, anomalous coronary origins, and intramyocardial
location (bridging) of epicardial coronary vessel.

Presenting Symptoms and Sign

The definition of typical angina pectoris has three components :
(a) SUBSTERNAL CHEST DISCOMFORT with characteristic quality and
duration that is (b) PROVOKED by exertion or emotional stress and (c)
RELIEVED by rest or nitroglycerin (NTG)

Atypical angina meets two of the three criteria, and noncardiac

chestpain meets one or none of the criteria
The typical duration of discomfort is 2 10 minutes.
Discomfort that lasts less than 1 minute is UNLIKELY to be
angina

 Pain that lasts longer than 10 minutes may be indicative of

UNSTABLE ANGINA, MYOCARDIAL INFARCTION, or
NONCARDIAC CHEST PAIN
The elderly and women in particular, are first seen more often
with atypical symptoms
Diabetics are more prone to heve episodes of silent ischaemia
and need intense care and evaluation

Patients with angina due to aortic stenosis or hypertrophic

cardiomyopathy have a characteristic systolic ejection murmur

Grading of Angina Pectoris by The Canadian

Cardiovascular Society Classification System
Class I
Ordinary physical activity, such as walking or climbing stairs, doesnt
cause angina
Angina (occurs) with strenouns, rapid, or prolonged exertion at work or
recreation

Class II
Slight limitation or ordinary activity; angina occurs on climbing stairs
rapidly, walking uphill, walking or stair climbing after meals, in cold,
in wind, under emotional stress, or only during the few hours after
awakening
Angina occurs on walking more than two blocks on the level and
climbing more than one flight of ordinary stairs at a normal pace and in
normal condition

Grading of Angina Pectoris by The Canadian

Cardiovascular Society Classification System
Class III
Marked limitation of ordinary physical activity; angina occurs on
walking one to two blocks on the level and climbing one flight of stairs
in normal conditions and at a normal pace

Class IV
Inability to carry on any physical activity without discomfort, anginal
symptoms may be present at rest

Electrocardiography
A resting 12-leads electrocardiogram (ECG) should be
obtained in all patients with symptoms suggestive of angina
pectoris.
The resting ECG is normal in approximately 50% of patient
with chronic stable angina.
ST-T changes are usually nonspecific.
Q waves may indicate previous MI.
LV hypertrophy may be caused by hypertension, aortic
stenosis, or hypertrophic cardiomyopathy.

Pathophysiology
Atherosclerotic plaque causing an important restriction to flow
may occur when luminal obstruction by the plaque is greater
than 50% for the left main artery or greater than 70% for the
remaining coronary arteries

Endothelial dysfunction and altered vasomotor reactivity is

also present in coronary arteries affected with atherosclerosis.
This leads to impaired vasodilatation or even vasoconstriction
in response to various stimuli, including excercise.

Differential Diagnosis

The differential diagnosis of chest pain includes numerous cardiac and noncardiac causes

Common cardiac causes of chest pain not attributable to myocardial ischaemia are
pericarditis and aortic dissection.

Pulmonary causes include pulmonary embolism, pulmonary arterial hypertension,

pneumothorax, pneumonia, and pleuritis.

Gastrointestinal causes are esophagitis, esophageal spasm or reflux, esophageal tears,

peptic ulcer disease, pancreatitis, and biliary tract diseases.

Musculoskeletal causes of chest pain are muscular strain or spasm, costochondritis,

fibromyalgia, rib fractures, cervical radiculopathy, and herpes zooster

Finally, chest pain may occur in patients with various psychiatric conditions, such as
anxiety and affective disorder

Complications
Stable angina can have significant adverse effect on a patient
quality of life and ,in its most severe forms, it negatively
affects an individuals exercise capacity and functional
independence.

The medical complications of stable angina are primarily those

that may ensure from CAD (i.e progression to unstable angina,
myocardial infarction, ischemic cardiomyopathy, congestive
heart failure, atrial and ventricular arrhytmias, and sudden
death)

Therapy
The goals of treatment are to relieve symptoms and to reduce the
risk of morbidity (e.g., MI) and mortality.
Ideally, succesful treatment result in a functional capacity of CCS
class I.
Contributing factors, such as anemia, hyperthyroidism, and poorly
controlled blood pressure, should be identified and treated.
The initial treatment program consists of the following:
A : aspirin, ACE inhibitors, antianginal therapy (nitrates, calcium channels
blockers, ranolazine)
B : blockers
C : cigarette-smoking cessation and cholesterol management
D : diet and diabetic therapy
E : education and exercise